Letters
The study by Dr Himelstein and colleagues1 included 689 myeloma.1 The CALGB 70604 (Alliance) trial was not re-
patients with metastatic prostate cancer. Although the study
protocol specified that previous chemotherapy or hormonal
treatment for metastatic disease was allowed for patients with
prostate cancer, no details were provided in the report1 about
the disease phase for metastatic prostate cancer. Conse-
quently, it is not clear if the enrolled patients had castration-
resistant prostate cancer or if there were some patients with
hormone-sensitive disease.
The margin predefined by the authors for the definition
of noninferiority (7%) is more than half the efficacy previ-
ously shown by zoledronic acid in patients with castration-
resistant prostate cancer 3 ; in that study, zoledronic acid
produced an 11% improvement in the incidence of skeletal-
related events compared with placebo (44% vs 33%). Even
if the 7% margin is considered acceptable, it is important that
a noninferiority trial be conducted in the same setting where
the control treatment previously showed efficacy.
Any difference in the study population, with the inclu-
sion of patients in a control group that has not shown efficacy
vs placebo, jeopardizes the validity and the interpretation of
the results. Including patients who have no proven benefits of
drug administration can mask potential between-group dif-
ferences, increasing the chances of declaring the noninferior-
ity of the experimental treatment.
Marcello Tucci, MD
Consuelo Buttigliero, MD
Massimo Di Maio, MD, PhD
Author Affiliations: University of Turin, San Luigi Gonzaga Hospital, Orbassano
(Turin), Italy (Tucci, Buttigliero); University of Turin, Ordine Mauriziano Hospital,
Turin, Italy (Di Maio).
Corresponding Author: Marcello Tucci, MD, Division of Medical Oncology,
Department of Oncology, University of Turin, San Luigi Gonzaga
Hospital, Regione Gonzole 10, 10043 Orbassano (Turin), Italy
(marcello.tucci@gmail.com).
Conflict of Interest Disclosures: The authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Di Maio
reported receiving personal fees from Eli Lilly, Merck Sharp & Dohme,
AstraZeneca, Novartis, Bristol-Myers Squibb, and Amgen. No other disclosures
were reported.
1. Himelstein AL, Foster JC, Khatcheressian JL, et al. Effect of longer-interval
vs standard dosing of zoledronic acid on skeletal events in patients with bone
metastases: a randomized clinical trial. JAMA. 2017;317(1):48-58.
2. Gartrell BA, Coleman RE, Fizazi K, et al. Toxicities following treatment
with bisphosphonates and receptor activator of nuclear factor-κB ligand
inhibitors in patients with advanced prostate cancer. Eur Urol. 2014;65(2):
278-286.
3. Saad F, Gleason DM, Murray R, et al; Zoledronic Acid Prostate Cancer Study
Group. A randomized, placebo-controlled trial of zoledronic acid in patients
with hormone-refractory metastatic prostate carcinoma. J Natl Cancer Inst.
2002;94(19):1458-1468.
4. Smith MR, Halabi S, Ryan CJ, et al. Randomized controlled trial
of early zoledronic acid in men with castration-sensitive prostate cancer
and bone metastases: results of CALGB 90202 (Alliance). J Clin Oncol. 2014;32
(11):1143-1150.
In Reply Dr Tanimoto and colleagues raise a valid point
about the apparent survival advantage of monthly zoled-
ronic acid, but not other bisphosphonates, when added to con-
ventional treatment for patients with untreated multiple
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stricted to untreated vs previously treated patients with mul-
tiple myeloma nor was it powered to address a survival end
point. Hence, given the potential survival benefit of zoled-
ronic acid in first-line treatment of multiple myeloma, clini-
cians and patients with multiple myeloma may want to have
a more focused discussion concerning the optimal dosing in-
terval of zoledronic acid.
Dr Tucci and colleagues correctly point out that the
CALGB 70604 (Alliance) trial eligibility criteria allowed pa-
tients with both castration-sensitive and castration-resistant
prostate cancer. For castration-sensitive prostate cancer, the
results of the CALBG 90202 (Alliance) trial reported by
Smith et al2 showed no effect with zoledronic acid vs placebo
to delay skeletal-related events or improve survival. These
results are contrasted with those in men with castration-
resistant prostate cancer, in which zoledronic acid or other
antiresorptive drugs have statistically significant effects
to delay or reduce skeletal-related events.3 The results of
CALGB 90202 (Alliance) were unavailable when CALGB 70604
(Alliance) was designed and enrolled patients from May 2009
to April 2012.
Whether men with prostate cancer had castration-
sensitive or castration-resistant prostate cancer was not cap-
tured in our database. We agree with the caution raised
by Tucci and colleagues in interpreting the noninferiority
of monthly vs every-3-month zoledronic acid as it applies
to men with castration-sensitive or castration-resistant pros-
tate cancer.
Andrew L. Himelstein, MD
Charles L. Loprinzi, MD
Charles L. Shapiro, MD
Author Affiliations: Helen F. Graham Cancer Center and Research Institute,
Newark, Delaware (Himelstein); Mayo Clinic, Rochester, Minnesota (Loprinzi);
Icahn School of Medicine at Mount Sinai, New York, New York (Shapiro).
Corresponding Author: Andrew L. Himelstein, MD, Helen F. Graham Cancer
Center and Research Institute, 4701 Ogletown-Stanton Rd, Ste 3400,
Newark, DE 19713 (ahimelstein@cbg.org).
Conflict of Interest Disclosures: The authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest and none
were reported.
1. Mhaskar R, Redzepovic J, Wheatley K, et al. Bisphosphonates in multiple
myeloma: a network meta-analysis. Cochrane Database Syst Rev. 2012;(5):
CD003188.
2. Smith MR, Halabi S, Ryan CJ, et al. Randomized controlled trial
of early zoledronic acid in men with castration-sensitive prostate cancer
and bone metastases: results of CALGB 90202 (Alliance). J Clin Oncol. 2014;32
(11):1143-1150.
3. El-Amm J, Aragon-Ching JB. Targeting bone metastases in metastatic
castration-resistant prostate cancer. Clin Med Insights Oncol. 2016;10(suppl 1):
11-19.
Coagulation Testing in a Bleeding Patient
To the Editor The Diagnostic Test Interpretation by Dr Choi and
colleagues1 highlighted 3 topics that deserve further discus-
sion: (1) utility of routine coagulation testing; (2) limitations
of a mixing study; and (3) appropriateness of a thrombophilia
evaluation in a bleeding patient.
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Prothrombin time has been validated for monitoring of
warfarin. Activated partial thromboplastin time has been vali-
dated for monitoring of intravenous heparin and screening for
hemophilia in affected families.2 These tests are frequently and
often erroneously used and can mislead clinicians into over-
investigating or underinvestigating patients. A prospective
study identified 94% of tests for prothrombin time and 99%
of tests for activated partial thromboplastin time were or-
dered unnecessarily.2 For the patient described in the article,
it was reasonable to order these tests because the patient was
bleeding, but the results could have been falsely normal due
to testing limitations.
A mixing study is often suggested as a screening test to de-
tect the presence of an inhibitor,3 but the poor sensitivity and
specificity are rarely discussed.3,4 Mixing studies are poorly vali-
dated in this context and depend heavily on preanalytic vari-
ables (eg, underfilling of the tube with blood, presence of a clot
in the tube), and the time required for performing them
(approximately 2 hours) can lead to delays in patient care.3 An
inhibitor to coagulation factor VIII, as in the presented case, is
the most common specific coagulation inhibitor. When factor
VIII inhibitor testing is available, physicians can proceed di-
rectly to performing this test without the delay of a mixing study.5
In centers where factor VIII inhibitor testing is not available, a
mixing study for the prolonged clotting assay may help deter-
mine if an inhibitor is present; however, mixing studies often
fail to correct completely when there are multiple clotting fac-
tor deficiencies. Clinicians should appreciate the limitations of
the mixing study and the possibility for misleading results. In
addition, because the patient’s prothrombin time was normal,
a mixing study for prothrombin time was not required.
Because the case presented by Choi and colleagues was of
a woman with excessive bleeding, lupus anticoagulant test-
ing was not required. Instead, this test should be reserved for
a subset of patients with thromboembolism or lupus rather than
for those who are bleeding—even those with a prolonged par-
tial thromboplastin time.
Assistance from coagulation laboratory staff is sug-
gested in complicated cases of coagulopathy to aid with
prompt diagnosis.
Michael Fralick, MD
Michelle Sholzberg, MDCM, MSc
Author Affiliations: Department of Medicine, St Michael’s Hospital, Toronto,
Ontario, Canada.
Corresponding Author: Michelle Sholzberg, MDCM, MSc, Coagulation
Laboratory, St Michael’s Hospital, 30 Bond St, Toronto, ON, Canada M5B 1W8
(sholzbergm@smh.ca).
Conflict of Interest Disclosures: Both authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were
reported.
1. Choi S-H, Rambally S, Shen Y-M. Mixing study for evaluation of abnormal
coagulation testing. JAMA. 2016;316(20):2146-2147.
2. Capoor MN, Stonemetz JL, Baird JC, et al. Prothrombin time and activated
partial thromboplastin time testing: a comparative effectiveness study
in a million-patient sample. PLoS One. 2015;10(8):e0133317.
3. Kershaw G, Orellana D. Mixing tests: diagnostic aides in the investigation
of prolonged prothrombin times and activated partial thromboplastin times.
Semin Thromb Hemost. 2013;39(3):283-290.
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Letters
4. Ajzner É, Rogic D, Meijer P, et al; joint Working Group on Postanalytical
Phase (WG-POST) of the European Federation of Clinical Chemistry
and Laboratory Medicine (EFLM) and European Organisation for
External Quality Assurance Providers in Laboratory Medicine (EQALM). An
international study of how laboratories handle and evaluate patient samples
after detecting an unexpected APTT prolongation. Clin Chem Lab Med. 2015;53
(10):1593-1603.
5. Tiede A, Werwitzke S, Scharf RE. Laboratory diagnosis of acquired
hemophilia A: limitations, consequences, and challenges. Semin Thromb Hemost.
2014;40(7):803-811.
In Reply We agree in principle with the comments from
Drs Fralick and Sholzberg that there are limitations to coagu-
lation testing, especially mixing studies. Ensuring accurate test
results and proper interpretation are important.
As explained in their comments, a normal prothrombin
time or partial thromboplastin time does not rule out the
presence of a coagulopathy or a bleeding disorder. These
tests should be considered screening tests with limitations
dependent on the reagent used by the individual laboratory.
We agree that a mixing study has limited sensitivity and
specificity, which can potentially lead to misleading results
and delays in patient care. At our institution, bleeding
history is used in determining whether to proceed with test-
ing for lupus anticoagulant or specific factor inhibitors. The
lupus anticoagulant test was performed in the patient
described in the Diagnostic Test Interpretation out of an
abundance of caution, given the history of stroke, despite the
bleeding history.
We agree that an alternative diagnostic approach is
to obtain individual clotting factor levels based on analysis
of which part of the coagulation cascade is affected prior
to obtaining the mixing study, provided this testing is
available at the designated health care facility. Individual fac-
tor activity assays are performed by serially diluting the
patient’s plasma with saline then mixing the diluted plasma
in a 1:1 ratio with reagent plasma deficient in the factor of
interest. Obtained clotting times are compared with those
of a reference curve derived from serial dilution of reference
or normal pooled plasma by saline and eventually mixed in
a 1:1 ratio with reagent factor-deficient plasma.1 In effect,
the mixing study is performed during the factor activity
assay. The 2 dose-response curves should be linear and
parallel if factor production deficiency is present. This con-
cept is known as nonparallelism. When the dose-response
curve of patient plasma is not parallel with the reference
curve, presence of an inhibitor or the factor in question is
then suspected.2 This procedure requires expert knowledge
and supervision of the factor assay procedure and may not be
reported in a commercial laboratory.
If the nature of the abnormality remains undefined after
factor activity assays, a mixing study can be performed to
differentiate between a clotting factor production defi-
ciency and an inhibitor. By obtaining the factor assay first,
the specific deficient factor would have been determined at
the same time the inhibitor was discovered. By performing
the mixing study first, one would only know about the pres-
ence of an inhibitor. To determine whether the interference
is specific for one factor (such as factor VIII), or nonspecific
(Reprinted) JAMA April 11, 2017 Volume 317, Number 14 1479
 Letters
(as with a lupus anticoagulant), additional assays including
factor activities would need to be performed.
Although we agree that obtaining factor assays first could
have led to a more expedient diagnosis, this approach would
be unfamiliar to general physicians, and only coagulation spe-
cialists would understand the technicalities of nonparallel-
ism. Thus the case was presented with the common diagnos-
tic approach. We recommend discussions with consulting
hematologists and coagulation laboratory specialists to en-
sure that appropriate testing is promptly performed and po-
tential sources of test interference are addressed.
Sung-hee Choi, MD
Siayreh Rambally, MD
Yu-min Shen, MD
Author Affiliations: Division of Hematology Oncology, University of Texas
Southwestern Medical Center, Dallas.
Corresponding Author: Sung-hee Choi, MD, Division of Hematology Oncology,
Department of Internal Medicine, University of Texas Southwestern
Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9047
(sung-hee.choi@utsouthwestern.edu).
Conflict of Interest Disclosures: The authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Shen reports
participation on speakers’ bureaus for Alexion and Janssen. No other
disclosures were reported.
1. Kjeldsberg C, Perkins S. Inherited coagulation disorders. In: Rodgers G, ed.
Practical Diagnosis of Hematologic Disorders. 5th ed. Chicago, IL: American Society
of Clinical Pathology Press; 2010:352-353.
2. Key N, Makris M, O’Shaughnessy D, Lillicrap D. Laboratory tests of
hemostasis. In: Kitchen S, Makris M, eds. Practical Hemostasis and Thrombosis.
2nd ed. Oxford, UK: Wiley-Blackwell; 2009:13-14.
FDA Approval of Eteplirsen for Muscular Dystrophy
To the Editor Drs Kesselheim and Avorn raised concerns about
the approval by the US Food and Drug Administration (FDA)
of eteplirsen to treat Duchenne muscular dystrophy (DMD),
such as reliance of the pivotal study on a surrogate measure.1
However, the 2012 Food and Drug Administration Safety and
Innovation Act allows accelerated approval of drugs to treat
rare and serious diseases based on surrogate end points that
are “reasonably likely to predict clinical benefit.”2 Thirteen
DMD experts spoke in support of accelerated approval for
eteplirsen at the Peripheral and Central Nervous System Drugs
Advisory Committee meeting.3 In addition, a letter to the FDA
from 36 experts concluded that the 12 treated boys in the
pivotal study are “clearly performing better than our collec-
tive clinical experience and the published literature would
predict”4 and “the findings of this trial are sufficiently robust
to support the proposed mechanism of action of eteplirsen,
to provide a plausible explanation for the relative gain in func-
tion observed within the treatment group, and serve to bol-
ster confidence that there is a positive treatment effect.”4
If the 13 experts at the advisory committee meeting sup-
ported accelerated approval, why did the external advisory
committee vote 7 to 6 against approval? We are concerned
that committee members may not have had sufficient knowl-
edge of DMD to make informed decisions. For example,
Kesselheim, a member of the advisory committee who voted
no, wrote in the Viewpoint that eteplirsen was designed to
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“bypass a stop codon in a gene coding for dystrophin”1 and
“eteplirsen targeted exon 51, the location of the stop codon.”1
In fact, eteplirsen is designed to restore the reading frame by
the exclusion of exon 51 from mature messenger RNA, lead-
ing to the production of an internally deleted dystrophin
protein.4 The Viewpoint also stated that DMD is “progressive
and usually fatal”4 and that “[n]o disease-modifying treat-
ments are available.”4 However, DMD is unfortunately uni-
formly fatal, but there is evidence that corticosteroids slow
disease progression.3,5
FDA Commissioner Robert Califf, MD, in a letter
explaining the decision,5 quoted from the FDA’s guidance
on expedited programs for serious conditions: “Determin-
ing whether an endpoint is reasonably likely to predict clini-
cal benefit is a matter of judgment that will depend on the
biological plausibility of the relationship between the dis-
ease, the endpoint, and the desired effect and the empirical
evidence to support that relationship.”2 This judgment must
come from a depth of knowledge of the disease and the
mechanism of action of the proposed therapeutic, and
should include expert opinion and flexibility in considering
atypical and small data sets.
Stanley F. Nelson, MD
M. Carrie Miceli, PhD
Author Affiliations: Center for Duchenne Muscular Dystrophy, David Geffen
School of Medicine at University of California, Los Angeles.
Corresponding Author: M. Carrie Miceli, PhD, University of California,
Los Angeles, 277 BSRB, 615 Charles E. Young Dr S, Los Angeles, CA 90095
(cmiceli@ucla.edu).
Conflict of Interest Disclosures: Both authors have completed and submitted
the ICMJE Form for Disclosure of Potential Conflicts of Interest. Drs Nelson and
Miceli reported receiving personal fees from Sarepta for advising on educational
materials for describing exon skipping; and having 2 patents pending for
identification of small molecules that facilitate therapeutic exon skipping.
Drs Nelson and Miceli were among the 13 experts who testified at the US Food
and Drug Administration (FDA) advisory committee and were coauthors of the
letter to the FDA.
1. Kesselheim AS, Avorn J. Approving a problematic muscular dystrophy drug:
implications for FDA policy. JAMA. 2016;316(22):2357-2358.
2. US Food and Drug Administration. Guidance for industry: expedited
programs for serious conditions—drugs and biologics. May 2014. https://www
.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation
/Guidances/UCM358301.pdf. Accessed February 12, 2017.
3. US Food and Drug Administration. Peripheral and Central Nervous System
Drugs Advisory Committee meeting [transcript]. April 25, 2016. https://www
.fda.gov/downloads/AdvisoryCommittees/CommitteesMeetingMaterials/Drugs
/PeripheralandCentralNervousSystemDrugsAdvisoryCommittee/UCM510390
.pdf. Accessed February 12, 2017.
4. Miceli MC, Nelson SF. The case for eteplirsen: paving the way for precision
medicine. Mol Genet Metab. 2016;118(2):70-71.
5. US Food and Drug Administration. Center for Drug Evaluation and Research
application No. 206488Orig1s000 summary review. September 16, 2016.
http://www.accessdata.fda.gov/drugsatfda_docs/nda/2016/206488_summary
%20review_Redacted.pdf. Accessed February 12, 2017.
To the Editor Drs Kesselheim and Avorn elucidated several im-
portant aspects of the FDA’s decision to approve eteplirsen to
treat DMD.1 How should clinicians and patients consider use
of eteplirsen in the setting of this devastating disease? Focus-
ing on the primary end points of the trial—dystrophin expres-
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